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Purpose and Method of Operation—FY 2001 Budget Policy

The purpose of the Research on Health Care Costs, Quality and Outcomes (HCQO) activity is to support and conduct research that improves the outcomes, quality, cost, use and accessibility of health care. Accordingly, the Agency has identified three strategic plan goals that feed into this budget activity:

The key themes throughout all three goals are to fund new research and to translate research into practice. In addition, AHRQ also has strengthened its commitment to support research that will improve health care for priority populations. Lastly, AHRQ has enhanced specific activities that support all of our strategic goals.

The Agency has made important strides toward meeting its strategic goals. This section review specific achievements in the Agency's core programs as well as activities initiated in response to the increase in the Agency's budget in FY 2001.

Support Improvements in Health Outcomes

One of the most important priorities of AHRQ is to translate and disseminate the findings of research supported by the Agency into tools and information that can be used by its customers to make good health care decisions and to improve the outcomes of care. The research supported by AHRQ has historically concentrated on conditions that are
common, costly, and for which there is substantial variation in practice. This research includes many of the conditions that represent major expenditures for Medicare and Medicaid. AHRQ's research attempts to reduce inappropriate variation and provide our health care decisionmaker with information on:

What care is appropriate.

Which clinical services work best in what circumstances and for which patients.

How much is enough.

What resources are used to provide it.

Outcomes research also attempts to help decisionmakers understand the implications of structural and financing changes in the health care system on the outcomes of care delivered in the system.

Outcomes Research

Outcomes and effectiveness research seeks to understand the end results of particular health care practices and interventions. End results include effects that people experience and care about, such as change in the ability to function. In particular, for individuals with chronic conditions—where cure is not always possible—end results include quality of life as well as mortality. By linking the care people get to the outcomes they experience, outcomes research has become the key to developing better ways to monitor and improve the quality of care. Supporting
improvements in health outcomes is a strategic goal of AHRQ.

For health care managers and purchasers, outcomes research can identify potentially effective strategies they can implement to improve the quality and value of care. AHRQ-sponsored outcomes studies, for example, have shown that even when treatments are known to be effective, many people who could benefit from them are not getting them.

Beta blocker medication, given after heart attacks, can reduce mortality; blood-thinning medication can prevent strokes; and thrombolytic ("clot-buster") therapy given immediately after a heart attack can reduce the damage from the
attack. Yet in each case, our research shows that many eligible patients are not getting these treatments. By identifying and addressing the barriers to better care—for example, through development of a tool to help doctors know which patients with suspected heart attacks will benefit from thrombolytic treatment—AHRQ researchers have helped translate these findings into practical strategies to improve care.

In FY 2000, AHRQ released the results of a Patient Outcomes Research Team (PORT) on depression. This study found that patients suffering from depression can have higher treatment rates, better health outcomes, and a higher chance of remaining employed for at least a year when treated in primary care practices using a specifically designed quality improvement program.

The PORT developed and tested evidence-based intervention materials (training guides, slides, brochures and videos) designed for clinicians, nurse specialists, psychotherapists and patients by incorporating them into a quality improvement program. They found that the materials helped manage the depression of 50 to 60 percent of patients in the test group versus 40 to 50 percent of the control group. The program did not require any services beyond those which already were covered by the patients' health plans. In addition, there was a 5% increase in the likelihood patients would still be employed after a year of treatment, showing that overall employment rates can be affected by improved
treatment. According to the researchers, this substantial improvement represents an even greater benefit if generalized to the larger population of depressed patients.

Examples of ongoing outcomes research supported in FY 2000 and 2001 are provided below.

FY 2000 and FY 2001—Examples of Outcomes Research Grants

Interventions to Improve Pain Outcomes—Pain is the most common and feared symptom of hospitalized patients. Despite evidence that approximately 90 percent of pain can be treated effectively with available therapies, unrecognized and under treated pain is widely prevalent in United States' hospitals. This research will take place in eight medical and surgical inpatient units at Mount Sinai with an estimated 3,000 patients over 21 months included in the study. Interventions designed to lessen pain in hospitalized patients will be tested and the impact on patients' self-reported pain intensity, pain relief, and satisfaction will be measured.

In addition to improving practice at Mount Sinai, this information will be used to create a generalizable model for pain management care that can be used by other inpatient hospitals.

TENNCARE Gaps for Children: Asthma Clinical Outcomes—Certain groups of children are known to be at high risk for adverse asthma outcomes, which include acute exacerbations leading to emergency department visits, hospitalizations, and death. These children at high risk of adverse outcomes include children in urban settings, minorities, and poor children—the same populations traditionally served by Medicaid programs. The proposed study is designed to quantify the effect of gaps in enrollment in Tennessee's Medicaid program for children with asthma using two clinical outcomes: emergency department visits and hospitalizations for asthma.

This evaluation will provide much needed information on the effects of specific policies or lack of policies (i.e. to ensure continuous enrollment for children with certain chronic illnesses) on clinical outcomes for high-risk children having one of the most common chronic health conditions in childhood.

Understanding Variability in Community Mammography—Though previous studies have shown variability in the interpretation of mammograms, they have not explained why it occurs and they used study designs that do not directly reflect what occurs in day-to-day community practices. This community-based study will use a unique collaboration among three breast cancer surveillance programs in the States of Washington, New Hampshire, and Colorado, allowing researchers to accumulate breast cancer outcome and interpretive data on more than 500,000 mammograms from 91 facilities and 279 radiologists. The researchers will evaluate potential factors influencing the accuracy and recall rates of mammography testing, using the hypothesis that the fiscal, legal, and community practice environment, and personal characteristics of the radiologist, influence variability in accuracy and the likelihood that patients will be recalled for additional evaluation.

Gaining a better understanding of how individual radiologists and their practice environment account for variation will help identify ways to improve the diagnostic accuracy of mammography.

Centers for Education and Research on Therapeutics (CERTs)

In FY 2000, AHRQ funded three new Centers for Education and Research on Therapeutics (CERTs), which the Agency administers in cooperation with the Food and Drug Administration. The CERTs program, initiated in September of 1999, was begun to improve the quality of health care and
reduce costs by:

Increasing awareness of the benefits and risks of new uses or combinations of medical products.

Improving the effectiveness of existing ones.

These Centers will also play a part in AHRQ's Patient Safety and Reducing Errors in Medicine agenda in the area of reducing adverse drug events.

AHRQ now supports seven CERTs for an investment of approximately $4.5 million in FY 2001. The newest centers are provided below:

Harvard Pilgrim Health Care CERT—This center will develop and determine the utility of large databases for studying the effectiveness and safety of antibiotic use in children, drugs for preventing congestive heart failure, and outcomes from the use of hypoglycemics in diabetics. It will also bring together nine members of the HMO Network and their researchers, as well as investigators with medical schools, schools of public health and pharmacy schools.

University of Pennsylvania CERT—This center will conduct research on ways to reduce resistance to antimicrobial drugs, drug utilization and subsequent intervention studies, medication safety studies, efficacy and effectiveness investigations and methodology studies.

University of Alabama at Birmingham CERT—This center is studying therapeutics used for rheumatoid arthritis, osteoporosis and other musculoskeletal diseases (MSD) and will disseminate new knowledge about MSD therapeutics, including their cost effectiveness and effects on health-related quality of life, and on ways to minimize the adverse effects of these therapeutics.

Other AHRQ-supported centers are located at Duke University, Georgetown University, the University of North Carolina, and Vanderbilt University.

Health of the Elderly

It is estimated that by the year 2020, 16 percent of the U.S. population will be age 65 or older. With the aging of America comes a greater need for information on how people can live healthier lives. Over time, AHRQ's research on aging has:

Clarified risks and benefits of many treatment options for patients with prostate disease, underscoring the need for patients to be involved in the decisionmaking process.

Led to increases in the use of beta-blockers by elderly heart attack patients, a therapy which can prevent future attacks and help reduce mortality.

Demonstrated that serious complications of hip replacement surgery among older patients are lower than originally thought.

Shown that increasing the nurse-to-patient ratio could translate to 3,000 fewer deaths per year in Medicaid-certified nursing homes.

In FY 2001, AHRQ will continue our commitment to research on the elderly, as well as research related to the health care conditions that, because of their severity or frequency, are the most costly to the Medicare program, including heart disease, pneumonia, and diabetes. Examples of research related to the elderly and/or medicare are below.

Examples of Grants Related to the Elderly and/or Medicare

Assisted Living and Health System Use. This project will examine how the characteristics of assisted living facilities affect the ways in which residents interact with the health and long-term care systems, specifically their use of Medicare-covered health services and transitions to other care settings (Texas Agriculture and Mechanical University).

Hospitalization of Nursing Facility Residents. This project will develop a comprehensive model of the determinants of nursing facility (NF) hospitalization rates that includes economic and environmental incentives, NF and resident characteristics, and differentiates types of hospitalization (Harvard University).

Measuring the Quality of Care for Diabetes. This study will use Medicaid data from six States to develop claims-based quality measures for ambulatory diabetes care. The States, selected because of a low prevalence of Medicaid managed care, are Kentucky, Pennsylvania, Alabama, Georgia, California, and Indiana (Harvard University).

Consequences of Drug Cost Sharing in the Elderly. Little is known about the intended and unintended effects on the elderly of differential cost sharing (DCS) for pharmaceutical costs, an increasingly common strategy to discourage use of more expensive medications in many drug benefits plans. In a pilot study, AHRQ found that a Canadian DCS policy reduced drug expenditures but was also associated with increased medication switching or stopping in vulnerable populations with low income or diagnoses of heart attack or heart failure.

This study will follow up on these findings and assess the impact of DCS applied to two heart drugs (angiotensin converting enzyme inhibitors and calcium channel blockers), on patterns of medication use and health care utilization in all elderly recipients of these drugs (Brigham and Women's Hospital).

Long-term Care

Long-term care is not just nursing home care; rather, it is a continuum of services beginning with respite care for the caregiver and home health care. With the "graying" of the American population, the spread of AIDS, and the growing awareness of the needs of non-elderly disabled people, more long-term care and service options will be needed.

The U.S. long-term care system has developed in a piecemeal manner, resulting in inefficiency and problems with access, quality, and financing. Public funding of long-term care is directed heavily toward institutionalization, especially nursing home care, which accounts for about 12 percent of public health care spending. AHRQ's research is directed toward projecting future service use and costs, studying alternative care settings, and finding more cost-effective ways of improving the delivery and quality of long-term care.

Research Finding. Americans who get hands-on help from others so that they can accomplish life's basic daily activities are not necessarily elderly nor do they all live in nursing homes. The latest available data show that an estimated 9.4 million adults, ages 18 and over, are given hands-on assistance to carry out either instrumental activities of daily living—chores such as shopping and housework—or for the more basic activities of daily living, such as bathing and dressing. Roughly 79 percent of these people live at home or elsewhere in the community rather than in institutions, and almost half are under 65 years of age.

In FY 2000, AHRQ funded a variety of grants and contracts related to long-term care. Examples of these grants are below.

Examples of Long-term Care Grants

Improving Pain Management in Nursing Homes. This study proposes to develop and implement an educational and behavioral intervention to improve the quality of pain assessment and management in 12 nursing homes. Residents who are cognitively impaired or are from racial/ethnic minority groups are at higher risk for inadequate analgesia. This study proposes to develop and implement a culturally-competent intervention to improve the quality of pain management. Development of the educational materials is based on principles of competency-based education and adult learning (University of Colorado Health Center).

Optimizing Antibiotic Use in Long-term Care.The primary objective of the proposed study is to determine if a clinical algorithm for managing urinary tract infections in older adults in residential long-tem care facilities (LTCFs) can reduce the overall use of antibiotics (McMaster University).

Secondary Drug Prevention of Stroke in Long-term Care. The overall goal of this study is to quantify the beneficial and unintended effects of drug therapy used in the secondary prevention of ischemic stroke in an elderly nursing home population. Of particular concern are the differences in treatment patterns and how they effect both mortality and rates of subsequent stroke (Brown University).

A Model for Use of the Urinary Incontinence Guideline in U.S. Nursing Homes. This study will test the effectiveness of a new model of care to translate the AHRQ Urinary Incontinence (UI) Guideline into practice in nursing homes. The model will utilize nurse practitioners in nursing homes to implement a carefully designed and focused effort to identify, work up, treat and follow up new cases of urinary incontinence on an ongoing basis—in collaboration with medical and nursing staff (University of Rochester).

Evidence-based Practice Centers (EPCs)

AHRQ currently funds research at 12 Evidence-based Practice Centers (EPCs) in the United States and Canada. These EPCs systematically review and analyze all relevant scientific literature on assigned clinical care topics, produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities.

In October 2000, AHRQ announced 15 new research topics for the EPCs.

Evidence-based Practice Centers (EPCs)

Evidence-based Practice Centers

Topic/Title

Nomination

New England Medical Center, Boston MA

Management of Allergic Rhinitis

Nominated by the American Academy of Family Physicians

University of California, San Francisco - Stanford University, San Francisco, CA

Autopsy as the Ultimate Outcome Measure

Nominated by the College of American Pathologists

McMaster University, Ontario, Canada

Impact of Cancer-related Decision Aids

Nominated by the National Cancer Institute

University of Texas Health Science Center, San Antonio, TX

Definition and Management of Chronic Fatigue Syndrome

Nominated by the National Institute of Allergy and Infectious Diseases

RAND, Santa Monica, CA

Diagnosis and Treatment of Congestive Heart Failure

Nominated by the American College of Physicians; American Society of Internal Medicine; American Academy of Family Physicians; and the Mayo Clinic.

New England Medical Center, Boston, MA

Criteria to Determine Disability of Infant /Childhood Impairment

Nominated by the Social Security Administration

MetaWorks®, Boston, MA

Diagnosis and Management of Parkinson's Disease

Nominated by the American Academy of Neurology

Duke University, Durham, NC

Management of Post-term Pregnancy

Nominated by the American College of Obstetricians and Gynecologists

ECRI, Plymouth Meeting, PA

Diagnosis and Treatment of Repetitive Motion Disorders

Nominated by the American College of Occupational and Environmental Medicine and the Social Security Administration

Research Triangle Institute and University of North Carolina, Chapel Hill, NC

Criteria for Determining Disability of Speech/Language Disorders

Nominated by the Social Security Administration

Oregon Health Sciences University, Portland, OR

Effectiveness and Cost-Effectiveness of Echocardiography and Carotid Ultrasound in the Evaluation and Management of Stroke

Nominated by the American Academy of Neurology

RAND, Santa Monica, CA

Utilization of Physicians' Services

Congressional Request

Research Triangle Institute and University of North Carolina, Chapel Hill, NC

Methods to Rate the Strength of Scientific Evidence

Congressional Request

Johns Hopkins University, Baltimore, MD

Training for a Rare Public Health Event of Bioterrorism

Congressional Request

University of California, San Francisco - Stanford University, San Francisco, CA

Role of Decision Support Systems in Disease Management Following a Bioterrorism Event

The topic was nominated by the American College of Cardiology and the American Heart Association Task Force on Practice Guidelines. Guidelines based on the Management of Stable Angina evidence report were developed by the American College of Cardiology and the American Heart Association, and published in the Journal of the American College of Cardiology in September 2000.

EPCs and Technology Assessments

AHRQ has been very successful in its partnerships with a wide variety of health care organizations. Our evidence reports are being used by professional associations to create clinical practice guidelines, as well as Federal agencies, academic institutions, patient groups and health systems. Examples of the uses of these evidence reports as well as our technology assessments follow.

The American Psychiatric Association (APA) used the "Depression Treatment with New Drugs" evidence report to develop their "Practice Guidelines for the Treatment of Psychiatric Disorders," which was published as a Supplement to the American Journal of Psychiatry, Volume 157, No. 4, April 2000, and also in a book published by the APA in 2000.

The Department of Veteran's Affairs (VA) is using our meta-analysis on "Testosterone Suppression Treatment for Prostate Cancer" as part of its continuing medical education program, and is disseminating results of the meta-analysis to VA medical personnel.

The American Academy of Pediatrics (AAP) developed practice guidelines based on our "Diagnosis of Attention-Deficit/Hyperactivity Disorder," and published them in the May 2000 AAP Journal, Volume 105, No. 5.

National Guideline Clearinghouse™ (NGC)

The National Guideline Clearinghouse™ (NGC), an Internet resource for evidence-based clinical practice guidelines
located at www.guideline.gov, has now been operational for 2 years. The NGC was developed by AHRQ, in partnership with the American Medical Association (AMA) and the American Association of Health Plans (AAHP), to be a resource for physicians, nurses and other health care professionals.

NGC has more than 900 clinical practice guidelines submitted by over 150 health care organizations and other entities. New guidelines are being added to NGC weekly. Over the last 2 years, NGC has had over 2 million visitors, processed over 23 million requests, and received over 42 million hits. NGC now has over 28,000 visits a week. The first annual customer satisfaction survey revealed that users were satisfied with NGC and found the site very useful.

"The NGC saves time for clinicians in practice settings. The layout of the Web site and the structured abstract format make it much easier to quickly compare similar guidelines by different organizations."

Dr. Goldstein is creating clinical practice guidelines on depression for primary care physicians in managed care settings. During this process he is using the NGC to review and compare existing guidelines on depression treatment and diagnosis.

Clinical Preventive Services

Premature deaths and disabilities due to preventable causes continue to exact a large toll in the United States. Health care providers and health care organizations play an essential role in national prevention efforts, by delivering effective vaccines, screening patients for early disease or risk factors, counseling about healthy lifestyles, and prescribing preventive medications. Despite steady progress in the delivery of effective preventive care, important gaps remain. As of 1998, more than one-third of women over 50 had not had a mammogram and breast exam in the last 2 years to screen for breast cancer. More than a third of older adults had not received a flu shot that year. Inequalities in preventive care also contribute to the disparities in the health of specific populations, such as racial and ethnic minorities, the elderly, and the poor and disabled.

In FY 2000, AHRQ funded a number of grants to evaluate the effectiveness of preventive services and examine ways improve the delivery of preventive care in the clinical setting. Several independent research projects were funded to examine the effectiveness of various interventions aimed at providers and patients—including Internet-based education, home-testing, and tools to assess patient risk—as a means to improve screening for chlamydia, an important cause of infertility in women. Other studies examined strategies to improve compliance with recommended prevention guidelines in special populations, including adolescents and African-Americans.

In 2001, AHRQ will fund additional projects with an emphasis on improving quality and addressing health disparities through better preventive care. Investigators in Boston are examining which types of computerized information are most effective in primary care settings for improving delivery of preventive care.

New assessments and recommendations will be made available through medical and nursing journals, on the AHRQ and National Guideline Clearinghouse™ web sites, and by print subscription. New assessments to be released later in the year include chemoprophylaxis for breast cancer (tamoxifen and other agents) and screening for depression. Assessments on a variety of new topics are beginning in 2001 including screening for thyroid disease (in conjunction with the Institute of Medicine); screening for family violence; and new approaches for prenatal testing.

AHRQ will continue to partner with CDC in the area of prevention. AHRQ's focus is clinical prevention, while CDC takes a public health approach. Together, the USPSTF and the CDC Guide to Community Preventive Services will outline the most effective ways to prevent disease and promote health across all settings, from doctors and nurses offices, to schools, workplaces, community organizations, health organizations, public health departments and State policy makers.

The Put Prevention into Practice (PPIP) program is working with outside partners to translate information from the USPSTF for audiences interested in prevention, including providers, patients, health plans, health departments, employers and other purchasers, as well as policymakers. A PPIP guide to help health departments, health plans, and practices implement a program to improve the delivery of preventive care will be released later in 2001.

Translating Research Into Practice. PPIP tools are part of the STEP-UP (Study To Enhance Prevention by Understanding Practice) clinical trial. STEP-UP, launched in 1997, involves 80 family practices and clinics across Northeast Ohio in urban, rural, and suburban areas, including large Amish populations.

The STEP-UP study evaluates a preventive service delivery intervention that is tailored to the unique characteristics of each practice. A nurse facilitator is assigned to each practice to identify special prevention-oriented needs of the practice population, such as immunizations, screenings, and counseling.

The STEP-UP manual provides tools for clinicians to use as-is or modify. PPIP materials included in the STEP-UP manual include adult and child preventive care flow sheets, child immunization flow sheets, posters, and patient reminder postcards. The STEP-UP trial plans to continue using PPIP tools because they can easily be adapted to clinicians' needs as they work to enhance the delivery of preventive services to local patient populations.

Domestic Violence

Domestic violence is a public health problem affecting millions of women and their families each year. It is the second leading cause of injuries and death among women of childbearing age and the leading cause of maternal mortality in at least two major cities. Domestic violence is prevalent among all racial and ethnic minority groups and is not exclusive to one socio-economic strata.

Domestic violence is a powerful predictor of increased health care utilization. Domestic violence has physical and emotional consequences for victims and their children. The consequences include acute injuries as well as chronic injury, chronic stress and fear, and lack of control over health care or support systems. These consequences are manifested in a range of medical, obstetric, gynecological, and mental health problems.

Research Finding. Direct health care costs to victims of domestic violence is estimated to be in the range of $1.8 billion dollars per year. One large health plan showed victims of intimate partner violence against women cost approximately 92 percent more than a random sample of general female enrollees.

In FY 2000, AHRQ funded four new research projects to improve treatment and outcomes for victims of domestic violence, a total investment over 5 years of $5.5 million. These grants will develop new knowledge in the prevention of domestic violence, improve the identification of female patients at risk, and evaluate outcomes and effectiveness of health care interventions designed to treat domestic violence victims.

Domestic Violence Grants

Treatment Outcomes for Abused Women in Public Clinics. This study will evaluate the effectiveness of nurse case management and group education for African-American, Hispanic, and White abused women attending two inner city primary care clinics. These two clinics are part of a county-wide clinic and hospital system for indigent citizens. In addition, researchers will evaluate the impact of the interventions on the health, functional status, and medical utilization of abused women's children (University of Texas Health Science Center).

A Randomized Control Trial of Computer Screening for Domestic Violence. This project will evaluate the effectiveness of a computerized assessment tool to enhance the ability of clinicians in emergency departments to identify potential victims of domestic violence and to recommend specific strategies for management. The study will enroll women who come to the emergency departments of two hospitals, one in the inner city and the other in the suburbs (University of Chicago).

The Cost and Benefits of Intervening: Battered Women's Mental and Physical Health Over Time. This study will compare and contrast seven existing domestic violence interventions located in different hospital settings. Findings from this study will offer new information on the effectiveness and cost effectiveness of different hospital-based interventions and is designed to identify effective programs and encourage their adoption (Harvard University).

Outcomes for Intimate Partner Violence: Patient and Provider Perspectives. This project will study 125 Latina women in prenatal clinics in San Francisco who are at risk for intimate partner violence (IPV). One of the primary objectives of this study is to ascertain women's preferences for health care outcomes from IPV interventions. The broad objectives are to develop methodologies for effectiveness research to assess and incorporate the heterogeneity of health problems associated with IPV among diverse populations (University of California at San Francisco).